Healthcare Provider Details

I. General information

NPI: 1780843854
Provider Name (Legal Business Name): LIESL R BULLEN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3960 NEW COVINGTON PIKE
MEMPHIS TN
38128-2504
US

IV. Provider business mailing address

1211 UNION AVE STE 330
MEMPHIS TN
38104-6655
US

V. Phone/Fax

Practice location:
  • Phone: 901-516-5741
  • Fax: 901-516-5986
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPN0000011962
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: